Intravenous Quetiapine-Cocaine Use (“Q-Ball”)

To the Editor: We have noted recent reports of quetiapine diversion and misuse among inmates in correctional settings where it is also called “quell” or “baby heroin” (1, 2) . It is used orally, intranasally, and intravenously for its potent sedative and anxiolytic properties (1, 2) . Inmates obtain quetiapine for illegitimate use by malingering of psychotic symptoms or obtaining it from other inmates. The high prevalence of substance use disorders in corrections and the secondary gain of serving out “easy time” with pharmacological assistance contribute to an underground economy of diverted psychoactive medications (3) . Anecdotal reports from colleagues—as well as online testimonials—support the existence of quetiapine diversion and misuse in noncorrectional settings as well (4) . The following case is an example of prescription medication diversion with concomitant illicit substance use seen in the local county hospital emergency room.

Combining prescription medications and/or illicit drugs is a common practice to synergistically heighten the intoxication from the substances while potentially reducing undesirable side effects. The combination of intravenous heroin and cocaine (also known as “speedball”) is a well-known strategy to both maximize the cocaine “rush,” while mitigating its “crash” (5) . It may be hypothesized that quetiapine was substituted for heroin in our case (to form a “Q-ball”) because the sedative/anxiolytic effects of quetiapine may mitigate the dysphoria associated with cocaine withdrawal and to possibly provide a “hallucinogenic” effect.

The case presented highlights the unknown effects (such as a “hallucinogenic” experience) of combining substances with different pharmacological properties and subsequently circumventing first-pass metabolism through intravenous administration. Individuals who use oral medications intravenously have the potential to develop significant pulmonary complications secondary to the deposition of medication binders in lung parenchyma. Furthermore, the cardiovascular and arrhythmogenic properties of cocaine may be amplified in combination with quetiapine (which has a risk of QTc prolongation). Physicians should remain cognizant of potential medication diversion and misuse in noncorrectional settings.